Provider First Line Business Practice Location Address: 
1605 N GARLAND AVE
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
GARLAND
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75040-9417
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-494-0004
    Provider Business Practice Location Address Fax Number: 
972-494-1177
    Provider Enumeration Date: 
09/27/2006